What Factors Are Associated With Having an Advance Directive Among Older Adults Who Are New to Long Term Care Services?

ObjectivesTo explore differences in having an advance directive among older adults newly transitioned to long term services and support (LTSS) settings (ie, nursing homes [NHs]; assisted living facilities [ALFs]; home and community-based services).DesignCross sectional survey.SettingLTSS in New York and Pennsylvania.ParticipantsParticipants were 470 older adults who recently started receiving LTSS. Included in this analyses, N = 442 (ALF: n = 153; NH: n = 145; home and community-based services: n = 144).MeasurementsInterviews consisted of questions about advance directives (living will and health care power of attorney), significant health changes in the 6 months before the start of long term care support services, Mini-Mental State Examination, and basic demographics.ResultsSixty-one percent (270/442) of older adults receiving LTSS reported having either a living will and/or an health care power of attorney. ALF residents reported having an advance directive more frequently than NH residents and older adults receiving LTSS in their own home (living will: χ²[2]= 120.9; P < .001; health care power of attorney: χ²[2]= 69.1; P < .001). In multivariate logistic regression models, receiving LTSS at an ALF (OR = 5.01; P < .001), being white (OR = 2.87; P < .001), having more than 12 years of education (OR = 2.50; P < .001), and experiencing a significant health change in past 6 months (OR = 1.97; P = .007) were predictive of having a living will. Receiving LTSS at an ALF (OR = 4.16; P < .001), having more than 12 years of education (OR = 1.74, P = .022), and having had a significant change in health in the last 6 months (OR = 1.61; P = .037) were predictive in having an health care power of attorney in this population of LTSS recipients.ConclusionsThese data provide insight into advance directives and older adults new to LTSS. Future research is needed to better understand the barriers to completing advance directives before and during enrollment in LTSS as well as to assess advance directive completion changes over time for this population of older adults.     

Prevalence of atrial fibrillation in US nursing homes: results from the National Nursing Home Survey, 1985-2004

ObjectivesTo evaluate the prevalence of atrial fibrillation (AFib) in US nursing homes from 1985 to 2004 and to project the prevalence of AFib to 2030.DesignThis study is an analysis of cross-sectional data from the US National Nursing Home Survey, years 1985, 1995, 1997, 1999, and 2004.SettingRandomly selected long term care facilities in the United States licensed by the state or certified for Medicaid/Medicare reimbursement.ParticipantsRandomly selected residents within study facilities.MeasurementsNational Nursing Home Survey demographics and current medical conditions data were analyzed. Population estimates were calculated using National Nursing Home Survey sample weights. Absolute observed annual linear growth of the AFib prevalence rate was calculated using linear regression. Predictive margins were estimated using logistic regression models to evaluate effect of changes in resident case-mix over the survey years. Three estimation methods predicted the number residents having AFib in 2030.ResultsThe sample sizes of surveyed resident groups were as follows: n = 5238 (1985); n = 8056 (1995); n = 8138 (1997); n = 8215 (1999); and n = 13,507 (2004). Prevalence rates of AFib by year were 2.8% (95% confidence interval [CI]: 2.3–3.4%; 1985), 5.1% (95% CI: 4.6–5.6%; 1995), 5.8% (95% CI: 5.3–6.3%; 1997), 6.9% (95% CI: 6.3–7.4%; 1999), and 10.9% (95% CI: 10.2–11.5%; 2004). Population estimates of nursing home residents with AFib (in thousands) were 42.2 (95% CI: 34.1–50.3; 1985), 78.7 (95% CI: 70.8–86.7; 1995), 93.6 (95% CI: 84.9–102.3; 1997), 111.8 (95% CI: 102.1–121.5; 1999), and 162.1 (95% CI: 152.4–171.7; 2004). Absolute annual linear growth in the prevalence rate of AFib was +0.38% observed (P = .022), +0.39% using unadjusted predictive margins (P = .007), and +0.37% using adjusted predictive margins (P = .007). Projected estimates showed that 272,000 (95% CI: 197,000–347,000), 300,000, or 325,000 residents would have AFib in the year 2030.ConclusionThe prevalence of AFib in US nursing home residents increased from 1985 to 2004 and is projected to grow substantially over the next 20 years, potentially resulting in an increased nursing home staff burden owing to increased stroke risk evaluations.     

Underrecognition and undertreatment of dementia in italian nursing homes

ObjectiveTo determine the prevalence of dementia diagnoses and the use of antidementia drugs in a cohort of Italian older nursing home (NH) residents.DesignCross-sectional study.SettingThe NH residents participating in 2 studies: the U.L.I.S.S.E. study and the Umbria Region survey.ParticipantsA total of 2215 nursing home residents.MeasurementEach resident underwent a comprehensive geriatric assessment at baseline by means of the RAI MDS 2.0. Dementia diagnosis was based on ICD-9 codes.ResultsThe prevalence of dementia diagnosis according to ICD-9 codes was 50.7% (n = 1123), whereas 312 subjects had cognitive impairment with a cognitive performance scale score ≥3 without a diagnosis of dementia. Only 56 NH residents were treated (5% of the sample) and the main drugs used were cholinesterase inhibitor, whereas only 1 subject was treated with memantine. Limiting our analysis to patients with mild to moderate Alzheimer's disease, who are those reimbursed by the public health care system for receiving antidementia drugs, the percentage rose to 11.3%.ConclusionThese findings demonstrate a high rate of underdiagnosis and undertreatment of dementia in Italian NH residents. Potential explanations include the lack of systematic assessment of cognitive functions, the limitations to antidementia drug reimbursement, the complexity of the reimbursement procedure itself, and the high prevalence of patients with severe dementia. Older NH residents still lack proper access to state-of-the-art diagnosis and treatment for a devastating condition such as dementia.     

Hypotension in Nursing Home Residents on Antihypertensive Treatment: Is it Associated with Mortality?

ObjectiveTo assess whether low systolic blood pressure (SBP) or diastolic blood pressure (DBP) due to antihypertensive medications might be related to mortality among nursing home (NH) residents.DesignObservational, longitudinal.SettingNursing home.ParticipantsAge ≥60 years, receiving antihypertensive medications.MeasurementsDemographic characteristics, mobility status, number of chronic diseases and drugs, nutritional status, and antihypertensive medications were noted. At the first visit, we recorded blood pressure (BP) measurements of last 1 year, which were measured regularly at 2-week intervals and considered their mean values. SBP and DBP thresholds were analyzed for mortality by ROC analysis. Multivariate Cox regression analyses were performed to determine factors related to mortality.ResultsThe sample included 253 residents with a mean age of 75.7 ± 8.7 years, and 66% were male. Residents were evaluated at a mean follow-up time of 14.3 ± 5.2 months (median: 15) for short-term mortality and 31.6 ± 14.3 months (median: 40) for long-term mortality. The prevalence of low SBP (≤110 mm Hg) and low DBP (≤65 mm Hg) was 34.8% and 15.8%, respectively. In follow-up, the short-term mortality rate was 21.7% (n = 55) and the long-term mortality rate was 42.2% (n = 107). Low SBP (≤110 mm Hg) was related to mortality in short- and long-term follow-ups [short-term follow-up: hazard ratio (HR) 3.7, 95% confidence interval (CI) 1.5-8.6, P = .01; long-term follow-up: HR 1.8, 95% CI 1.1-3.0, P = .02], adjusted for age, mobility status, nutritional state, and total number of diseases and drugs. Low DBP (≤65 mm Hg) was related to mortality in short- and long-term follow-ups [short-term follow-up: HR 3.0, 95% CI 1.2-7.8, P = .02, long-term follow-up: HR 2.8, 95% CI 1.5-5.2, P = .001], adjusted for age, mobility status, nutritional state, and total number of diseases and drugs.Conclusions and ImplicationsSystolic hypotension was found in more than one-third of the NH residents receiving antihypertensive treatment. Low SBP and DBP were significant factors associated with mortality. Particular attention should be paid to prevent low SBP and DBP in NH residents on antihypertensive treatment.     

Potentially Harmful Medication Prescribing by the Degree of Physician Specialization in Nursing Home Practice: An Observational Study

ObjectivesThe use of anticholinergics, antipsychotics, benzodiazepines, and other potentially harmful medications (PHMs) is associated with particularly poor outcomes in nursing home (NH) residents with Alzheimer's disease and related dementias (ADRD). Our objective was to compare PHM prescribing by NH physicians and advanced practitioners who focus their practice on NH residents (NH specialists) vs non-NH specialists.DesignRetrospective cohort study.Setting and ParticipantsWe included a 20% random sample of Medicare beneficiaries with ADRD who resided in 12,278 US NHs in 2017. Long-stay NH residents with ADRD were identified using MDS, Medicare Parts A and B claims. Residents <65 years old or without continuous Part D coverage were excluded.MethodsPhysicians in generalist specialties and advanced practitioners with ≥90% of Part B claims for NH care were considered NH specialists. Residents were assigned to NH specialists vs non-NH specialists based on plurality of Part D claims submitted for that resident. Any PHM use (defined using the Beers Criteria) and the proportion of NH days on a PHM were modeled using generalized estimating equations. Models included resident demographics, clinical characteristics, cognitive and functional status, behavioral assessments, and facility characteristics.ResultsOf the 54,713 residents in the sample, 27.9% were managed by an NH specialist and 72.1% by a non-NH specialist. There was no statistically significant difference in any PHM use [odds ratio (OR) 0.97, 95% CI 0.93-1.02, P = .23]. There were lower odds of prolonged PHM use (OR 0.87, 95% CI 0.81-0.94, P < .001, for PHM use on >75% vs >0%-<25% of NH days) for NH specialists vs non-NH specialists.Conclusions and ImplicationsAlthough the use of PHMs among NH residents with ADRD managed by NH specialists was not lower, they were less likely to receive PHMs over longer periods of time. Future work should evaluate the underlying causes of these differences to inform interventions to improve prescribing for NH residents.     

Management and Outcomes of ST-Elevation Myocardial Infarction in Nursing Home Versus Community-Dwelling Older Patients: A Propensity Matched Study

ObjectivesThe influence of admission source (nursing home [NH] versus community-dwelling) on treatment strategies and outcomes among elderly patients with ST-elevation myocardial infarction (STEMI) has not been investigated.ParticipantsNationwide Inpatient Sample databases from 2003 to 2010 were used to identify 270,117 community-dwelling and 4082 NH patients 75 years of age or older with STEMI.DesignRetrospective observational study.MeasurementsPropensity scores for admission source were used to assemble a matched cohort of 3081 community-dwelling and 3132 NH patients, who were balanced on baseline demographic and clinical characteristics. Bivariate logistic regression models were then used to determine the associations of NH with in-hospital outcomes among matched patients.ResultsIn-hospital mortality was significantly higher in patients with STEMI presenting from a NH as compared with community-dwelling patients (30.5% versus 27.6%; odds ratio [OR] 1.15, 95% confidence interval [CI] 1.03–1.29; P = .012). Overall, NH patients were less likely to receive reperfusion (thrombolysis, percutaneous coronary intervention, or coronary artery bypass grafting) (11.5% versus 13.4%; OR 0.84, 95% CI 0.72–0.98; P = .022). However, rates of percutaneous coronary intervention alone were similar in both groups (9.9% in NH versus 9.1% in community-dwelling; OR 1.10, 95% CI 0.93–1.30; P = .276). Mean length of stay was also similar in both groups (5.68 ± 5.40 days in NH versus 5.69 ± 4.98 days in community-dwelling, P = .974).ConclusionCompared with their community-dwelling counterparts, older NH patients are less likely to receive reperfusion therapy for STEMI and have higher in-hospital mortality.     

Ambulatory Blood Pressure Monitoring in Older Nursing Home Residents: Diagnostic and Prognostic Role

BackgroundOlder subjects living in nursing homes (NHs) show a high prevalence of multimorbidity, disability, and cognitive impairment. The clinical meaning of arterial hypertension (AH) in this population is unclear, and few studies have adopted ambulatory blood pressure monitoring (ABPM) with this purpose.The aims of the study were to evaluate the concordance between office and monitored blood pressure in a sample of NH residents and to assess the prognostic meaning of ABPM parameters after 1 year.MethodsNH residents underwent a comprehensive geriatric assessment and 24-hour ABPM (Spacelabs 90207). White-coat hypertension (WCH) was defined as office blood pressure of 140/90 or higher and ABPM lower than 135/85 mm Hg. Vital status was assessed after 1 year.ResultsA total of 100 residents (mean age 83, 51% affected by AH) showed WCH in 33% of cases and in 70% of cases elevated office blood pressure. Correlation between monitored and office blood pressure was limited for systolic (R = 0.30) and nonsignificant for diastolic blood pressure (R = 0.11). Disability and behavioral disorders were independently associated with 1-year mortality. No ABPM parameter, except low nighttime systolic blood pressure variability, was associated with 1-year mortality.ConclusionsConcordance between office and ABPM values is limited, and WCH prevalence is high among NH residents. Survival at 1-year follow-up is predicted by disability and behavioral disorders, but is not associated with blood pressure values.     

Disparities in hypertension control advice according to smoking status

ObjectivesHypertension is the most common modifiable cardiovascular risk factor. Blood pressure (BP) reduction, particularly among smokers, is highly effective at preventing cardiovascular diseases. We examined the association between patient smoking status and hypertension management advice.MethodsAdults who participated in the 2007 Behavioral Risk Factor Surveillance System with self-reported hypertension were examined (n = 51,063). Multivariable logistic regression analysis controlling for age, gender, race/ethnicity, education, marital status, insurance status, body mass index, alcohol use, self-reported general health and survey design were conducted to examine the association between smoking status (never, former, or current) and receipt of hypertension control advice.ResultsAfter controlling for potential confounders, being a current smoker was significantly associated with lower odds of receiving advice to lower salt intake (Adjusted Odds Ratio, AOR, 0.91 [95% confidence interval = 0.84–0.99]), exercise (AOR 0.89 [0.80–0.98]), and to take hypertensive medication (AOR 0.80 [0.66–0.98]) compared to never smokers. However, hypertensive smokers had greater odds of receiving advice to reduce alcohol consumption (AOR 1.23 [1.10–1.45]).ConclusionsAlthough healthcare providers are in an optimal position to provide patient education to improve BP control, hypertensive smokers may be less likely to receive important BP control lifestyle modification messages from their healthcare provider than non-smokers.     

Profiling the multidimensional needs of new nursing home residents: evidence to support planning

IntroductionNursing home (NH) residents have various needs that affect the care they require. This article describes the diverse needs that new NH residents have, emphasizing the proportion of people with milder needs in multiple areas.MethodsResearch was conducted on all older adults newly admitted to not-for-profit NHs in the Winnipeg Health Region, between April 1, 2005, and March 31, 2007, provided that they were assessed using the Resident Assessment Instrument Minimum Data Set (RAI/MDS 2.0) within 30 days of admission (n = 1061). Using the Activities of Daily Living (ADL) Hierarchy scale, residents were first defined as low, intermediate, or high ADL dependent. Residents' needs were also defined using the RAI/MDS 2.0 cognitive performance (CPS) and pain scales, by their degree of behavioral problems and visual challenges, and by their frequency of bladder and bowel incontinence. Cluster analysis was used to create subgroups of residents by their severity of clinical challenges.ResultsOf our cohort, 26.8% were low ADL dependent. Although some of these residents had moderate to severe needs in another area, many (46.8% of low ADL-dependent residents; 12.5% of our entire cohort) had milder needs across all clinical domains. Conversely, about one-third of our cohort was high ADL dependent; 31.7% of these residents had moderate to severe challenges in one clinical domain, and 35.5% had moderate to severe comorbid challenges.ConclusionsOverall, 12.5% of our cohort had lower needs, demonstrating the capacity for community-based programs to offset NH demands. Also, the diversity of residents' needs highlights the importance of having both the appropriate resources and strategies available to provide quality NH care. Future research is discussed for both low- and higher-need NH residents.     

Determining the Incidence of Drug-Associated Acute Kidney Injury in Nursing Home Residents

Objective

Although acute kidney injury (AKI) is well studied in the acute care setting, investigation of AKI in the nursing home (NH) setting is virtually nonexistent. The goal of this study was to determine the incidence of drug-associated AKI using the RIFLE (Risk, Injury, Failure, Loss of kidney function, or End-Stage kidney disease) criteria in NH residents.

Design/Setting/Participants/Measurements

We conducted a retrospective study between February 9, 2012, and February 8, 2013, for all residents at 4 UPMC NHs located in southwest Pennsylvania. The TheraDoc™ Clinical Surveillance Software System, which monitors laboratory and medication data and fires alerts when patients have a sufficient increase in serum creatinine, was used for automated case detection. An increase in serum creatinine in the presence of an active medication order identified to potentially cause AKI triggered an alert, and drug-associated AKI was staged according to the RIFLE criteria. Data were analyzed by frequency and distribution of alert type by risk, injury, and failure.

Results

Of the 249 residents who had a drug-associated AKI alert fire, 170 (68.3%) were women, and the mean age was 74.2 years. Using the total number of alerts (n = 668), the rate of drug-associated AKI was 0.41 events per 100 resident-days. Based on the RIFLE criteria, there were 191, 70, and 44 residents who were classified as AKI risk, injury, and failure, respectively. The most common medication classes included in the AKI alerts were diuretics, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEIs/ARBs), and antibiotics.

Conclusion

Drug-associated AKI was a common cause of potential adverse drug events. The vast majority of cases were related to the use of diuretics, ACEIs/ARBs, and antibiotics. Future studies are needed to better understand patient, provider, and facility risk factors, as well as strategies to enhance the detection and management of drug-associated AKI in the NH.     

Efficiency at the Resident's Level of the NABUCCOD Nutrition and Oral Health Care Training Program in Nursing Homes

ObjectivesTo assess the impact of a nutrition and oral care training program on nursing home (NH) policies and residents.DesignCross-sectional surveys before/after intervention.ParticipantsOne hundred thirty-eight NHs participated in the initial training.InterventionTraining sessions for staff, director, and medical practitioners for nutritional and oral care in NH.MeasurementsTwo waves of self-assessments over a 6- to 8-month interval described NH policies (Institution questionnaire), quality of care in newly admitted residents (Admission questionnaire), and in those present for more than 6 months (Stay questionnaire).ResultsQuestionnaires were completed at both waves in 24 NHs (17.8%) for Institution, in 42 NHs including 646 residents for Admission, and in 34 NHs including 287 residents for Stay. There was no significant difference in bed capacity and resident dependency between NHs, which performed both assessments, and nonresponders. No change was observed for Institution. Malnutrition screening was carried out in almost all residents. Two risk factors were better screened after training: pressure ulcers (39.4% to 49.1%, P = .014) and dysphagia (33.5% to 41.0%, P = .049). Oral examination improved quantitatively (38.5% of residents to 48.5%) and qualitatively: risk factors for malnutrition and dysphagia were better sought (loss of posterior teeth (P < .0001), asialia (P < .0001), and candidosis (P = .002)). Similar improvements were seen in Stay assessments. Actions to counteract weight loss or low dietary intake records were not found in one third of resident records.ConclusionsTraining program improved staff knowledge with positive results at the level of residents but no significant changes were seen within NH policies.     

Risk of death associated with use of PPIs in three cohorts of institutionalized older people in Finland

ObjectivesTo (1) explore clinical and demographic characteristics of users and nonusers of PPIs in 3 cohorts of institutionalized older people in Finland, and (2) compare the risk of death associated with use of PPIs in each setting.DesignCross-sectional assessment of 3 institutionalized cohorts with 1-year follow-up of all-cause mortality.Setting and ParticipantsA total of 1389 residents of 69 assisted living facilities (first cohort), 1004 residents of long term care hospitals (second cohort), and 425 residents in acute geriatric wards or in nursing homes (third cohort).MeasurementsDemographic, drug use, and diagnostic data were collected during structured assessments conducted by trained nurses or geriatricians. Cox proportional hazards models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between use of PPIs and mortality.ResultsIn the assisted living facility, the mortality was 20.2% (n = 74) and 20.4% (n = 208) among users and nonusers of PPIs, respectively (P = 0.94). PPIs were not associated with mortality in unadjusted or adjusted analyses. In the long term care hospitals, use of PPIs was associated with increased mortality (HR, 1.36; 95% CI 1.04–1.77) when adjusted for age, sex, comorbidity, use of SSRIs, and malnutrition. In the acute geriatric wards and nursing homes, use of PPIs was associated with increased mortality (HR, 1.90; 95% CI 1.23–2.94) when adjusted for age, sex, comorbidity, delirium, and use of aspirin and SSRIs.ConclusionPPIs were not associated with mortality among residents in assisted living facilities, but were associated with increased mortality in settings where residents experienced higher levels of disability and possible susceptibility to adverse drug events.     

Prevalence of Thiamin Deficiency in Ambulatory Patients with Heart Failure

BackgroundThiamin is a required coenzyme in energy production reactions that fuel myocardial contraction. Therefore, thiamin deficiency (TD) may aggravate cardiac dysfunction in patients with systolic heart failure (HF).ObjectiveTo determine the prevalence of TD in ambulatory participants with HF as well as the relationships between thiamin status and HF severity, dietary thiamin intake, diuretic use, and circulating neurohormones.DesignA cross-sectional study comparing the prevalence of TD in ambulatory patients with HF with that of controls. Demographic, anthropometric, nutrition, medication use, and heart function data were collected from direct interviewing, questionnaires, and medical records. Blood samples were obtained to measure levels of neurohormones and assess TD.Participants/settingFifty age-matched control participants without HF and 100 outpatients with HF and reduced left ventricular function were recruited from clinics at St Michael’s Hospital, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada, between September 2009 and February 2011.Main outcome measuresTo assess TD, erythrocyte thiamin pyrophosphate (TPP) was measured using high-performance liquid chromatography. TD was defined as TPP<6.07 μg/dL (180 nmol/L).Statistical analyses performedPrevalence rates were analyzed using χ² test. Nonparametric statistics (Jonckheere-Terpstra, Kruskal-Wallis, Spearman’s correlation) were used to assess TPP levels in relation to HF severity, medication use and plasma concentrations of F2-isoprostanes, norepinephrine, and N-terminal pro-brain natriuretic peptide (NT-proBNP).ResultsThere was no significant difference in the prevalence of TD in outpatients with HF (6%) and controls (6%) (P=0.99). No relationship was found between heart function, thiamin intake, use or dose of diuretics, and TD. A positive relationship was observed between erythrocyte TPP and F2-isoprostane levels (r_s=0.22, P=0.03) but not between erythrocyte TPP and norepinephrine (P=0.45) and NT-proBNP (P=0.58).ConclusionThe prevalence of TD was low in ambulatory HF participants suggesting that, unlike hospitalized patients, ambulatory patients may be at a low risk for TD.     

The Treatment of Hypertension in Care Home Residents: A Systematic Review of Observational Studies

AimTo describe the prevalence of hypertension in care home residents, its treatment, change in treatment over time, and the achievement of blood pressure (BP) control.MethodThe PubMed, Cochrane, Embase, and PsychINFO databases were searched for observational studies involving care home residents with a diagnosis of hypertension. The search was limited to English language articles involving adults and humans published from 1990 onward. Abstracts and titles were reviewed with eligible articles read in full. Bibliographies were examined for further relevant studies. The final selection of studies was then analyzed and appraised.ResultsSixteen articles were identified for analysis, of which half were studies carried out in the United States. The prevalence of hypertension in care home residents was 35% (range 16%–71%); 72% of these were on at least 1 antihypertensive (mean 1.5 antihypertensives per individual), with diuretics being the most common. The prevalence of hypertension in study populations was greater in more recent studies (P = .004). ACEi/ARBs (P = .001) and β-blockers (P = .04) were prescribed more frequently in recent studies, whereas use of calcium-channel blockers and diuretics remained unchanged over time. The number of antihypertensives prescribed per patient was higher (correlation 0.332, P = .009), whereas fewer patients achieved target BP (correlation −0.671, P = .099) in more recent studies.ConclusionHypertension is common in care home residents and is commonly treated with antihypertensive drugs, which were prescribed more frequently in more recent studies but with no better BP control. These studies indicate a tendency toward increasing polypharmacy over time, with associated risk of adverse events, without demonstrable benefit in terms of BP control.     

Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial

RationaleExcess mortality and residual disability are common after hip fracture.HypothesisTwelve months of high-intensity weight-lifting exercise and targeted multidisciplinary interventions will result in lower mortality, nursing home admissions, and disability compared with usual care after hip fracture.DesignRandomized, controlled, parallel-group superiority study.SettingOutpatient clinicParticipantsPatients (n = 124) admitted to public hospital for surgical repair of hip fracture between 2003 and 2007.InterventionTwelve months of geriatrician-supervised high-intensity weight-lifting exercise and targeted treatment of balance, osteoporosis, nutrition, vitamin D/calcium, depression, cognition, vision, home safety, polypharmacy, hip protectors, self-efficacy, and social support.OutcomesFunctional independence: mortality, nursing home admissions, basic and instrumental activities of daily living (ADLs/IADLs), and assistive device utilization.ResultsRisk of death was reduced by 81% (age-adjusted OR [95% CI] = 0.19 [0.04–0.91]; P < .04) in the HIPFIT group (n = 4) compared with usual care controls (n = 8). Nursing home admissions were reduced by 84% (age-adjusted OR [95% CI] = 0.16 [0.04–0.64]; P < .01) in the experimental group (n = 5) compared with controls (n = 12). Basic ADLs declined less (P < .0001) and assistive device use was significantly lower at 12 months (P = .02) in the intervention group compared with controls. The targeted improvements in upper body strength, nutrition, depressive symptoms, vision, balance, cognition, self-efficacy, and habitual activity level were all related to ADL improvements (P < .0001–.02), and improvements in basic ADLs, vision, and walking endurance were associated with reduced nursing home use (P < .0001–.05).ConclusionThe HIPFIT intervention reduced mortality, nursing home admissions, and ADL dependency compared with usual care. Australian New Zealand Clinical Trials Registry (ACTN12605000164695).     

MDS 3.0: Brief Interview for Mental Status

ObjectivesTo test the feasibility and validity of the Brief Interview for Mental Status (BIMS) as a performance-based cognitive screener that could be easily completed by nursing home staff. The current study examines the performance of the BIMS as part of the national testing of the Minimum Data Set 3.0 (MDS 3.0) for Nursing Homes.MethodsThe BIMS was tested as part of the national MDS 3.0 evaluation study among 3822 residents scheduled for MDS 2.0 assessments. Residents were from 71 community nursing homes (NHs) in eight states. Residents were randomly included in a feasibility sample (n = 3258) and a validation sample (n = 418). Cognition was assessed with three instruments: the Brief Interview for Mental Status (BIMS), the MDS 2.0 Cognitive Performance Scale (CPS), and the Modified Mini-Mental State Examination (3MS). Trained research nurses administered the 3MS and BIMS to all subjects in the validation study. The CPS score was determined based on the MDS 2.0 completed by nursing home staff who had undergone additional training on cognitive testing. Standard cutoff scores on the 100-point 3MS were used as the gold standard for any cognitive impairment (<78) and for severe impairment (<48). Staff impressions were obtained from anonymous surveys.ResultsThe BIMS was attempted and completed in 90% of the 3258 residents in the feasiblity sample. BIMS scores covered the full instrument range (0–15). In the validation sample, correlation with the criterion measure (3MS) was higher for BIMS (0.906, P < .0001) than for CPS (–0.739, P < .0001); P < .01 for difference. For identifying any impairment, a BIMS score of 12 had sensitivity = 0.83 and specificity = 0.91; for severe impairment, a BIMS score of 7 had sensitivity = 0.83 and specificity = 0.92. The area under the receiver operator characteristics curve, a measure of test accuracy, was higher for BIMS than for CPS for identifying any impairment (AUC = 0.930 and 0.824, respectively) and for identifying severe impairment (AUC = 0.960 and 0.857, respectively). Eighty-eight percent of survey respondents reported that the BIMS provided new insight into residents' cognitive abilities. The average time for completing the BIMS was 3.2 minutes.DiscussionThe BIMS, a short performance-based cognitive screener expressly designed to facilitate cognitive screening in MDS assessments, was completed in the majority of NH residents scheduled for MDS assessments in a large sample of NHs, demonstrating its feasibility. Compared with MDS 2.0 observational items, the BIMS performance-based assessment approach was more highly correlated with a criterion cognitive screening test and demonstrated greater accuracy. The majority of surveyed staff reported improved assessments with the new approach.     

Characterization and Comparison of Physical and Mental Health Profiles and Department of Veterans Affairs Health Care Utilization Patterns among Operation Iraqi Freedom/Operation Enduring Freedom Women Veterans in Puerto Rico versus the United States

BackgroundResearch on the physical and mental health profiles and patterns of health care use among women veterans receiving health care from the Department of Veterans Affairs (VA) on the island of Puerto Rico is lacking.MethodsThis cross-sectional study examines differences in physical and mental health conditions, and patterns of VA health care use, between women veterans of the Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) era who were using VA facilities in Puerto Rico (n = 897) and those using U.S.-based VA facilities (n = 117,216) from 2002 to 2015.ResultsResults of fully adjusted logistic regression models revealed that OIF/OEF women in Puerto Rico had heightened risk for global pain-related disorders (i.e., any pain) (adjusted odds ratio [AOR], 1.45; 95% confidence interval [CI], 1.22–1.71), back pain (AOR, 1.83; 95% CI, 1.56–2.14), diabetes (AOR, 1.42; 95% CI, 1.03–1.95), hyperlipidemia (AOR, 3.34; 95% CI, 2.80–3.98), major depression (AOR, 1.78; 95% CI, 1.53–2.06), and bipolar depression (AOR, 1.66; 95% CI, 1.34–2.04). They also evidenced greater risk for a host of reproductive health conditions and had higher average annual use of VA health care than their U.S. counterparts.ConclusionsOIF/OEF women receiving VA health care in Puerto Rico evidenced a greater burden of physical illness, depression, and heightened use of VA health care services relative to their U.S. counterparts. Providers’ increased awareness of the physical and mental health care needs of this population is warranted. Research efforts that help to identify efficient and effective strategies to provide culturally tailored and/or personalized health care for this population could also be useful.     

Impact of the sustained control of cardiovascular risk factors on first episode heart failure: The relevant role of primary care

Background: The role of cardiovascular risk factor control in the development of heart failure (HF) has not yet been clearly established.

Objective: To determine the effect of cardiovascular risk factor control on the occurrence of a first episode of hospital admission for HF.

Methods: A case-control study using propensity score-matching was carried out to analyse the occurrence of first hospital admission for HF taking into account the degree of cardiovascular risk factor control over the previous 24 months. All patients admitted to the cardiology unit of the Hospital del Mar between 2008 and 2011 because of a first episode of HF were considered cases. Controls were selected from the population in the hospital catchment area who were using primary care services. Cardiovascular risk factor measurements in the primary healthcare electronic medical records prior to the first HF episode were analysed.

Results: After the matching process, 645 participants were analysed (129 HF cases and 516 controls). Patients suffering a first HF episode had modest increments in body mass index and blood pressure levels during the previous two years. Adjusted odds ratio for experiencing a first HF hospital admission episode according to systolic blood pressure levels and body mass index was (OR: 1.031, 95% CI: 1.001–1.04), and (OR: 1.09, 95% CI: 1.03–1.15), respectively.

Conclusion: Increased levels of body mass index and systolic blood pressure during the previous 24 months may determine a higher risk of having a first HF hospital admission episode.